Hearing: “1-800 MEDICARE: It’s Time for a Check-Up”

I. INTRODUCTION

Good morning Chairman Kohl, Ranking Member Smith and other distinguished members of the Committee, my name is Tatiana Fassieux. I am Board Chair of California Health Advocates (CHA) and Program Manager for the Health Insurance Counseling & Advocacy Program – HICAP, of PASSAGES, in Chico, CA.

California Health Advocates (CHA) is an independent, non-profit organization dedicated to education and advocacy efforts on behalf of Medicare beneficiaries in California. As Board Chair for the past 4 1/2 years, I have provided direction and support of the organization’s mission of Medicare beneficiary advocacy and education for Californians, and the work of 24 HICAPs – California’s State Health Insurance Assistance Program, or SHIP.

As a HICAP manager for more than 9 years, I have been responsible for the Medicare counseling program serving more than 45,000 Medicare beneficiaries in 5 Rural Northern California counties offered by PASSAGES, which also is a designated Area Agency on Aging, PSA 3. This non-profit agency is a project of the Research Foundation of California State University, Chico.

I want to thank the committee for inviting me to testify on behalf of CHA and California’s Medicare beneficiaries about experiences we have had with 1-800-MEDICARE.

This written testimony will focus on 4 issues:

The importance of 1-800-MEDICARE;

The myriad problems with 1-800-MEDICARE’s performance;

The resulting impact on SHIPs and Medicare beneficiaries; and

Recommendations for improvement.

II. IMPORTANCE of 1-800-MEDICARE

Since the introduction of Part D, the Medicare prescription drug benefit, and the expansion of Medicare Advantage plans, we have worked hand-in-hand with 1-800- MEDICARE in providing the “local” support that beneficiaries needed during these challenging times. We have had clients referred to the HICAPs by 1-800-MEDICARE customer service representatives (CSRs), and frequently we have reciprocated because we knew that 1-800-MEDICARE was a 24-7 benefit that should be taken advantage of. When we refer clients to 1-800-MEDICARE, though, we should be able to expect that they will be provided with accurate and timely information.

HICAPs routinely call 1-800-MEDICARE to verify beneficiaries’ records, to file complaints on behalf of beneficiaries, etc. – that is, to do the work that the HICAPs are expected to do. And we have had improved experiences with the introduction of counselor unique ID numbers and the new SHIP-only telephone number to access CSRs at 1-800-MEDICARE. However, as discussed below, our confidence in the ability of 1-800-MEDICARE has been shaken frequently based upon our experiences as well as those of our clients.

III. PROBLEMS WITH 1-800-MEDICARE

Many calls to 1-800-MEDICARE result in a positive outcome, and it is our understanding that the performance of this phone line is, overall, gradually improving. Sometimes callers get good service and accurate answers. Due to the nature of our work, however, we are less likely to hear about success stories with 1-800-MEDICARE than problems experienced by our clients. Based upon the experience of SHIP programs and the clients they serve, the rate of unsuccessful calls – in terms of getting through, obtaining accurate information, and resolving problems – is still far too high. In short, it is still hit or miss whether a caller will receive accurate information and/or have their problem resolved.

The following section breaks down ongoing 1-800-MEDICARE problems into two general categories: access to services; and the resolution of individual beneficiaries’ problems.

A. ACCESS

The first challenge for callers is to get through to someone who can help them. Medicare beneficiaries and SHIP programs alike experience ongoing difficulties accessing assistance through the 1-800-MEDICARE phone line due to issues such as long wait times, disconnected calls, and frustrations with the interactive voice response (IVR) system.

Long wait times

When calling 1-800-MEDICARE, both SHIP counselors and their clients report wait times of varying length. According to one HICAP counselor, it typically takes 30 minutes to 1 hour to reach someone who can help with an issue. Another reports that it usually takes 15-20 minutes to get to the 1st layer of CSRs, and an additional 15-30 minutes to reach the second layer of help (Tier 2 CSRs). A third HICAP manager reports that “extended delays in responses during the day are still occurring, depending on the day or time of the week.”

Disconnected Calls

Although less rampant than in the past, disconnects or dropped calls (on the 1-800-MEDICARE end instead of a caller hanging-up) are still occurring with regularity. Disconnects occur during the initial wait to speak with a CSR as well as during transfers to Tier 2 CSRs.

Example: According to some SHIP counselors, sometimes disconnects seem to occur when CSRs are unable to answer particular questions posed to them. Many cut-offs occur when supervisors are asked for. One SHIP manager reports speaking with a 1-800-MEDICARE supervisor who admitted that he was aware that such purposeful disconnects or hang-ups occurred among hotline CSRs.

Interactive Voice Response (IVR) System

In an attempt to provide callers with the ability to have certain questions answered or questions redirected automatically, 1-800-MEDICARE instituted the interactive voice response (IVR) system. Out of a need to preserve valuable time, SHIPs have learned how to bypass the IVR by saying “agent” or pressing “0.” Most beneficiaries, however, are unaware of how to bypass or navigate the IVR, and many express frustration with the system. Medicare beneficiaries often complain about long wait times for a “live” person, and don’t like dealing with voice prompts. Common beneficiary complaints about the IVR include:

it is too complicated for seniors; if one doesn’t know to press zero or ask for agent, 3 cycles go by before you are put in queue for a CSR;

it is not sensitive to individuals who speak with accented English, and the Spanish IVR doesn’t always recognize various Spanish dialects (let alone provide services to individuals who speak languages other than English or Spanish);

some individuals who have hearing aids have trouble hearing or dealing with the IVR.

Limited English Proficient (LEP) Individuals

Despite CMS assurances that 1-800-MEDICARE CSRs can assist beneficiaries in any language, 1-800 MEDICARE continues to provide insufficient support for limited English proficient callers.

Example: According to the National Senior Citizens Law Center and the California Medicare Part D Language Access Coalition, a Chinese-speaking caller was recently transferred by a Part D plan to 1-800-MEDICARE, where she said, “Chinese, please” several times. The operator was quite disrespectful, asked her to speak in English, and then hung up on her. According to the Coalition, examples such as this, as well as a broader failure to accommodate LEP callers, are all too common.

In a similar vein, one of our colleague organizations that works with the Deaf Community reports complaints about 1-800-MEDICARE hanging up on individuals trying to use a phone relay service, and concern that 1-800-MEDICARE lacks videophone relay service.

B. PROBLEM RESOLUTION

In addition to challenges with accessing the services of 1-800-MEDICARE, beneficiaries and SHIP counselors often face difficulties with trying to have questions answered and problems resolved. All too often, 1-800-MEDICARE callers are unable to: obtain accurate information; troubleshoot various issues that impede access to Medicare services; speak to the right person/entity relating to an individual problem; and lodge complaints.

Misinformation

Although many questions are answered correctly by 1-800-MEDICARE CSRs, sometimes they are unable to answer simple questions. SHIP counselors report inconsistent answers on the same issues, and sometimes false, misleading, or inaccurate information provided.

Examples of misinformation given by 1-800-MEDICARE CSRs, as reported by HICAP managers, include:

enrollees of Medicare Advantage Prescription Drug plans (MA-PDs) can change plans at any time (resulting in clients being locked-in or locked out of plans);

incorrect timing of Medicare enrollment periods ( resulting in beneficiaries missing opportunities to enroll in or change plans); and

“those who answer the phone [at 1-800-MEDICARE] have not had enough training to really understand Medicare and associated parts. When beneficiaries call and try to describe what they want help with, the CSRs don’t know the questions to ask them to find out more specifically what the other aspects of their problem and/or situation is. Unless the right trigger words are used, the caller is likely to get “automatic” answers and be referred to the wrong department. More often than not, they refer them to their SHIP, which is OK, but certainly an extra step for the caller, who probably had to wait a while to get to the referral. Let’s face it, the CSR’s are unable to perform the retroactive disenrollments, and answer the difficult questions that require research …”

Access to CMS and Other Contractors

Over the last year or so, CMS turned 1-800-MEDICARE into a single point of entry for access to their myriad contractors (such as Part B carriers, intermediaries, Medicare Administrative Contractors (MACs) – collectively referred to as fee for service (FFS) call centers). In addition, CMS largely cut off SHIPs’ access to local CMS Regional Offices, which had previously assisted SHIPs with resolving complex cases. When 1-800-MEDICARE became the main point of entry, SHIPs lost much of their ability to handle and correct their clients’ problems in a timely manner.

Instead of direct access to CMS contractors, SHIPs and their clients must contend with 1-800-MEDICARE CSRs who now try to handle complex questions that normally require resolution by a contractor, or wait for 1-800-MEDICARE to email the appropriate claims contractor about the caller’s inquiry (hopefully resulting in a return email or call back from the contractor). Other barriers arise when SHIPs and beneficiaries are referred between 1-800-MEDICARE and private Part D and Medicare Advantage plans that claim that the other is the appropriate entity to contact.

Example: According to one HICAP counselor who was able to reach representatives from a Part B carrier through backdoor channels, the carrier informed her that information forwarded to them by 1-800-MEDICARE CSRs is sometimes wrong and/or incomplete which prevents the carrier from resolving the client’s issue.

Sometimes misinformation coupled with the inability to resolve problems can be life threatening for Medicare beneficiaries.

Example: A HICAP counselor in Southern California assisted a transplant patient who was informed by her pharmacy that she would no longer be eligible for her anti-rejection medication. The counselor called 1-800-MEDICARE to invoke an escalated or expedited emergency procedure, but the CSR — following an erroneous script — insisted that no Medicare beneficiaries are entitled to lifetime coverage of anti-rejection medication, and also claimed that there was no “expedited” complaint resolution process, and that normal case resolution takes 30 days. After 4 or 5 separate phone calls to 1-800-MEDICARE and several conversations with supervisors, the counselor finally found a CSR who both recognized the severity of the client’s situation, and acknowledged that there was indeed an expedited complaint resolution process. The CSR collected the information provided by the counselor and explained that the case would be forwarded to the local CMS Regional Office (RO). Following protocol provided by CMS, the counselor waited a few days and contacted the local CMS RO, only to learn that there was no record of the client’s complaint in the computer system.

Some Medicare beneficiaries run into barriers even speaking with CSRs when trying to resolve problems.

Example: A HICAP client, a widow, called 1-800-MEDICARE about her late husband’s Medicare account relating to some billing questions. The CSR at 1-800-MEDICARE said that she had to have a signed authorized representative form in order to proceed.

Enrollment/Disenrollment Processing

SHIPs regularly complain that 1-800-MEDICARE is unable to accurately process enrollments into and disenrollments from Medicare Part D and Medicare Advantage plans, particularly retroactive disenrollments. In order to successfully help their clients with enrollment and disenrollment issues, SHIP counselors often must spend hours on the phone; other times, counselors are only able to obtain prospective disenrollments on behalf of their clients.

Example: A HICAP counselor was told by a 1-800-MEDICARE CSR that she couldn’t get a retroactive disenrollment for a client until the client received a disenrollment letter from her plan. The counselor also was told conflicting information about whether to subsequently contact 1-800-MEDICARE or the local CMS Regional Office.

Example: The daughter of a deceased Medicare beneficiary reported to her local HICAP that she had to work for months in order to get her mother retroactively disenrolled from her Medicare Advantage plan.

Example: A HICAP counselor from Central California recently tried to assist a husband and wife with disenrolling from the same Medicare Advantage plan, but 1-800-MEDICARE CSRs only processed the wife’s disenrollment, leaving the husband needing – but unable to find – medical care. As a result of marketing misconduct by a Medicare Advantage agent engaged in unsolicited door-to-door sales, Mr. and Mrs. M. were enrolled in an MA plan they did not want. A HICAP counselor phoned 1-800-MEDICARE with the couple in an attempt to help them get out of their MA plan. The HICAP counselor gave the details to the first CSR. After being transferred, she gave the same details to the 2nd CSR who then requested to speak with Mrs. M., who in turn responded to duplicative questions as to the allegation that the she did not understand what she had purchased. The CSR then enrolled her into a PDP. Mr. M. was then requested to provide his testimony to the very same issue, however his primary language is Spanish so they were put on hold again for a Spanish speaking CSR. Mr. M. underwent the same litany of questions, however, according to the HICAP counselor, he is not as articulate as his wife so the questioning was exceedingly lengthy. By this time, Mr. M. was sweating profusely and appeared very anxious before the CSR started the enrollment process into a PDP for him as well. The total call time was an hour and forty minutes. Together the HICAP counselor and couple had encountered the same line of questioning four times. While Mrs. M. was successfully enrolled in a stand alone PDP, Mr. M. remained in the MA plan. A subsequent call to 1-800-MEDICARE revealed that the PDP plan had not processed the application. Follow up calls (totaling 115 minutes) to the MA plan finally revealed that 1-800-MEDICARE did not approve the PDP Special Enrollment Period (SEP) therefore prompting another 55 minute call to1-800-MEDICARE. The CSR insisted that Mr. M had to complete the enrollment process into the plan all over again. The CSR further stated that she didn’t ‘think it would be possible to get a retroactive enrollment date of 8-1-08’ (even though the original enrollment occurred 7-24-08). In the meantime, Mr. M. has been postponing necessary medical care until the disenrollment from the MA plan occurs. Although he needs medical attention, he has been unable to find a provider who is willing to accept the MA plan he is stuck in.

Lodging and Monitoring Complaints

As part of efforts to centralize and streamline various Medicare functions, 1-800-MEDICARE has been tasked with recording complaints that come to their attention through the Complaint Tracking Module (CTM). Based upon the experience of SHIP programs, though, we are concerned that the full scope of problems experienced by Medicare beneficiaries are not being accurately recorded, if at all, in the CTM system, resulting in a failure to accurately track systemic problems. Many callers report that they must use “magic words” in order to get a complaint lodged (including firmly stating that they want to “lodge a complaint in the Complaint Tracking Module”). Some SHIPs encounter CSRs who are ignorant about the role of SHIP programs themselves, begging the question whether beneficiaries who need help from SHIP programs are being referred correctly.

Example: One HICAP counselor reports that while trying to lodge a complaint about marketing misconduct surrounding the sale of a Medicare plan a 1-800-MEDICARE CSR claimed that there is nothing wrong with an insurance agent enrolling a beneficiary who has Alzheimer’s.

Example: A HICAP counselor who also works on anti-fraud efforts through the Medicare Senior Medicare Patrol (SMP) program tried to report fraud impacting one of her clients but encountered a CSR who argued with her about what constituted Medicare “fraud.” The CSR told her – “well, that’s just you’re version, so how are you going to prove it?” In other words, the CSR was making determinations about what is fraud and what isn’t, and refused to lodge a complaint concerning alleged fraud. The same HICAP/SMP counselor reports that in general, 1-800-MEDICARE CSRs aren’t providing information on MEDICs (CMS fraud contractors) and typically won’t accept fraud-related complaints.

Example: A HICAP counselor who called 1-800-MEDICARE to lodge a complaint about a Medicare plan was discouraged from doing so by a CSR and was told that “a complaint is serious.”

IV. IMPACT on SHIPs and MEDICARE BENEFICIARIES

The problems getting through to and obtaining accurate, timely assistance and information from 1-800-MEDICARE amplifies problems faced by beneficiaries and SHIP programs trying to assist them. When an individual’s Medicare problem is not addressed by knowledgeable people, the problem often snowballs into a much larger, more time consuming problem than if it had been addressed at the outset.

SHIPs

At a time when SHIPs are being asked to do more and more with fewer resources, problems with 1-800-MEDICARE increase the burden on SHIPs. When 1-800-MEDICARE fails to adequately assist a Medicare beneficiary, SHIP counselors must step in and pick up the pieces, stretching limited resources even further. Frustration with 1-800-MEDICARE has forced some SHIPs to find alternate ways of dealing with their clients’ problems, if available (e.g. if relations are good with their local CMS RO).

The California SHIP program was recently given access to a special direct SHIP line the last week of August 2008, so we have not yet had extensive experience with it. Feedback so far, though, is mixed – for those whose unique ID numbers are in the system, it has seemed to work well; others who don’t have their numbers in the system are unable to access this line. While access to a designated SHIP line will likely improve the ability of SHIPs to perform their casework, the existence of and need for special designated SHIP lines – both for 1-800-MEDICARE as well as individual Part D and Medicare Advantage plans – highlight the shortcomings of all of these phone lines for the general public.

Medicare Beneficiaries

SHIP counselors are generally able to tell when they get bad information from a 1-800-MEDICARE CSR, but the general public is less able to do so, and more likely to rely upon bad information. We continue to be concerned about how many beneficiaries are still struggling either financially and/or with accessing medical benefits because their questions or problems were not resolved through 1-800-MEDICARE. If these individuals are unable to find a SHIP program to assist them, they are largely without recourse.

1-800-MEDICARE is a lifeline for many Medicare beneficiaries. Many of them, though, are frustrated by long wait times and simply hang up before they are able to speak with a CSR, or are stymied by the IVR. Some that get through are not well served by the information and assistance they receive. Rural beneficiaries in particular need to be assured that they can get accurate and prompt information, because many don’t have access to a Social Security office or a nearby SHIP counseling site. In short, while SHIPs encounter problems assisting their clients, Medicare beneficiaries on their own are far more vulnerable and susceptible to the shortcomings of a system that is inconsistent in its performance.

V. CONCLUSION & RECOMMENDATIONS

While 1-800-MEDICARE is able to handle many calls appropriately, there are still far too many performance problems encountered by SHIPs and their clients. Barriers to problem resolution impact the ability of SHIPs to do their work, and more importantly, has negative consequences for beneficiaries whom they are trying to serve.

In order to improve the 1-800-MEDICARE phone line so that it better serves the Medicare program, we offer the following recommendations:

CMS must employ stronger oversight of the contactor administering the hotline, including:

better training of CSRs; they must:

be able to answer basic questions

be able to adequately triage cases

be able to identify when they are unable to answer a question

strengthen and revise CSR scripts

including instances where callers should be referred to SHIPs for more state-specific information (e.g. Medigap rights)

CMS should form a taskforce consisting of SHIPs and other advocates to help review and/or write 1-800-MEDICARE scripts and training materials.

The IVR system must be improved, including giving callers the option to bypass the prompts once they enter their Medicare number.

CMS should explore the performance and experience of other hotlines. For example, the California Public Employee Retiree System (CalPERS) operates a phone system whereby if a caller does not get a live person during an initial call, s/he will receive an electronic instruction informing them that a live representative will call them back in “X” number of minutes – and such calls actually occur.

SHIPs should be provided with more access to other contractors and more information in order to properly assist their clients, including:

SHIPs should be able to find out what happens with complaints lodged, including calls back

SHIPs should be provided with direct access to CMS contractors, such as carriers and intermediaries

absent significant improvement for all callers to 1-800-MEDICARE, all SHIPs should be provided with access to a direct SHIP line and CMS should make frequent updates to SHIP unique ID numbers.

About Karen Fletcher

Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.

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